Volume 20 - Número 4
EDITORIAL
Golden Jubilee of Cardiopulmonary bypasses in Brazil: a date to be celebrated
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
SPECIAL ARTICLE
50 years of cardiopulmonary bypass in Brazil: Hugo J. Felipozzi, the pioneer of cardiopulmonary bypass in Brazil
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
ORIGINAL ARTICLE
Papillary muscle repositioning: the gold standard technique to repair anterior mitral leaflet prolapse
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: The aim of this study was to demonstrate that papillary muscle repositioning is a reliable technique to repair anterior leaflet prolapse. Therefore we describe this technique and its long term results to propose it as a gold standard.
Method: Between 1989 and 2005, 120 mitral valve repairs were consecutively performed using papillary muscle repositioning in cases of anterior leaflet prolapse. There were 87 males and 33 females, the mean age was 59 ± 11.5 years. 59% of patients were in NYHA III or IV. Mean ejection fraction was 65.7 ± 8.9%. Predominant aetiology of mitral regurgitation (MR) was degenerative: Barlow (n=43) and dystrophic (n=62). The other aetiologies were: healed endocarditis (n=5), rheumatic (n=5), ischemic (n=4), congenital (n=1). A posterior papillary muscle repositioning was performed in 111 (92.5%) cases and an anterior in 38 (31.7%). Associated procedures were carried out in 76 (63.3%) patients.
Results: There were no in-hospital deaths. During the follow-up, 14 patients (11.7%) died, including seven (5.8%) due to cardiac causes. The cumulated survival rates at 1, 5, 10 and 15 years were 98.3%, 97.2%, 94.1% and 81.4% respectively. Two patients (1.7%) were reoperated for recurrency of the regurgitation, they underwent a replacement of the valve 1 and 5 years after the repair and died 3 and 6 years, respectively after this replacement. There was no systolic anterior motion. The cumulated survival rates free from reoperation involving the mitral valve at 1, 5, 10 and 15 years were 97.4%, 97.4%, 92.8 % and 86.7% respectively. We did not find any risk factor of mortality or of reoperation. The follow-up was completed for all the patients. After a median follow-up time of 5.9 years (range from 0.1 to 15.6 years) 87 patients were in NYHA class I (72.5%), the echographic control showed no or minimal insufficiency in 89 patients (74.2%), mild insufficiency in eight patients (6.7%) and moderate insufficiency in nine patients (7.5%).
Conclusions: Papillary muscle repositioning is a reliable and safe technique, with excellent clinical and echocardiographic long term results. Therefore we propose it as a gold standard to repair anterior leaflet prolapse.
Keywords: Heart valve prolapse; Mitral valve insufficiency, surgery; Mitral valve, surgery
Coronary artery bypass grafts in patients with coronary stents
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To observe the surgical characteristics of patients operated on after percutaneous coronary intervention (PCI).
Method: Fifty-six patients (41 M and 15 F), by the time of coronary artery by-pass grafts (CABG), already had undergone coronary stenting procedures. In 101 PCI, 116 stents were implanted. By the time of the first PCI, 32 patients had three or more coronaries with severe stenosis. Six patients were treated with PCI for severe left main stem stenosis. Since the implantation of the first stent, 12 patients developed severe de novo lesions in the left coronary trunk. In six of these, the stenosis was developed in 6 months after the implant of the stent. Diabetes was present in 35.7% of the patients. In 22 patients (39.2%), at the time of CABG, the left ventricular (LV) function was reduced (p<0.001). At surgery, 160 grafts were implanted. Surgical studies included coronary and muscle biopsy.
Results: Surgical observation showed arteritis and inflammatory tissues adjacent to the stent in comparison to other areas. Seventeen patients that could not have antiplatelets drugs withdrawn needed more blood transfusion. There were no hospital deaths.
Conclusion: In patients operated on after stents implantation, facts like loss in LV function or de novo vascular lesions add complexity to surgical cases and may impair long-term results. Due to endothelial dysfunction caused by stents, grafts may close earlier. In addition, the efficiency of clinical therapy may not be the same.
Keywords: Stents; Myocardial revascularization; Coronary arteriosclerosis
Ministernotomy in off-pump coronary artery bypass surgery
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: Patients with isolated lesions in the proximal left anterior descending artery (LAD) have been demonstrated to benefit more from surgical treatment than percutaneous coronary intervention (PCI). However, with the less invasiveness of PCI, the majority of the patients have been referred for this latter procedure. We report herein on the inferior ministernotomy approach for the treatment of patients with single LAD lesions, with off-pump anastomosis of the left internal thoracic artery graft.
Method: Fourteen patients, consecutively operated on using this technique with the LITA graft anastomosed to the LAD, were examined. The mean age of the patients was 56.7 ± 10.1 years. The length of the skin incision varied from 7 to 9 cm and only the distal sternum was split longitudinally. The anastomosis was facilitated with the use of an Octopus-3 stabilizer (Medtronic).
Results: All patients had satisfactory postoperative outcomes, the length of postoperative hospital stay ranged from 2 to 6 days (median 3 days). No ECG changes or enzymatic rises were seen in this series. One patient was re-admitted for wound infection.
Conclusion: The ministernotomy approach allows safe accomplishment of off-pump LAD grafting, providing the long-term benefits of using the LITA.
Keywords: Surgical procedures, minimally invasive; Myocardial revascularization, methods; Mammary arteries; Sternum, surgery
The impact of new preventive measures and treatment of surgical site infections after coronary artery bypass graft surgery
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To assess the impact of new preventive measures of surgical site infections after coronary artery bypass graft (CABG) surgery.
Method: A retrospective study of 468 patients who underwent CABG surgery with cardiopulmonary bypass was performed. These patients were distributed into two groups: Group A (n=224) and Group B (n=244), respectively before and after a new protocol. The two groups were compared by statistical analysis to determine differences in risk factors, the incidence of sternotomy surgical site infections (superficial and deep), recurrent infections and hospital readmission.
Results: There was a greater use of internal thoracic artery grafts (p=0.003) and a shorter time of mechanical ventilation (p=0.001) in Group B. Surgical site infections occurred in 44 patients of Group A (19.6%); 33 superficial (14.7%) and 11 deep (4.9%) while in Group B only 13 patients had this complication (5.3%); 10 superficial (4.1%) and three deep (1.2%) surgical site infections. Significant improvements were seen in the total number of surgical site infections (p<0.001), of superficial infections (p<0.001) and of deep infections (p=0.037). There were 36.3% and 7.7% of recurrent infections in Groups A and B, respectively (p=0.102). Hospital readmissions due to surgical site infections were 21 in Group A and three in Group B (p<0.001).
Conclusion: The new preventive measures and treatment for surgical site infections after CABG surgery in this series of patients, significantly reduced the incidence of sternotomy surgical site infections and hospital readmissions related to this complication.
Keywords: Infection; Surgical wound infection; Infection control; Cardiac surgical procedures; Myocardial revascularization
Permanent cardiac pacing in children with postoperative bradycardia: long-term follow-up
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To evaluate the long-term outcomes of children submitted to permanent cardiac pacing due to postoperative bradycardia and to identify risk factors for mortality.
Methods: From 1980 to 2004, 120 children were submitted to permanent pacemaker (PM) implantation. Interval between the defect correction and PM implantation was 1.2 ± 2.8 years, on average (median = 21 days). Atrioventricular blocks were present in 94.2% of patients. Transvenous leads (78.3%) and ventricular pacemaker systems (79.2%) were used in most of the cases. Risk factors were studied using the Cox proportional model. The Kaplan-Meier method and the Log-Rank test were used to analyze survival.
Results: After a mean of 5.7 ± 5.9 years (maximum = 22.5 years) of follow-up, 97 patients were alive and 11 were lost from the follow-up study. The main causes of death were terminal heart failure (10), infection not related to implantation (six), and sudden death (three). The 5-, 10-, and 15-year survival rates were 80.9 ± 4.1%, 75.4 ± 5.5% and 67.2 ± 7.4%, respectively. The persistence of hemodynamic problems (palliative procedures, the use of valve prostheses or the presence of residual defects) was identified as the only independent risk predictors for mortality, with significant alterations in the survival curves (p=0.0123).
Conclusion: The implant of permanent pacemakers in children provided good survival expectancy, mainly depending on the underlying disease and the type of the correction made. Palliative corrections, such as the presence of residual defects or valve prostheses were the only predictors of poor results in these children.
Keywords: Cardiac pacing, artificial; Heart block; Pediatrics; Cardiac surgical procedures; Postoperative complications
Analysis of the inicial eight years of activities of the Human Heart Valve Bank of the Hospital de Caridade da Irmandade da Santa Casa de Misericórdia de Curitiba
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: The aim of this study was to retrospectively evaluate the first eight years of activities of the Human Heart Valve Bank of Hospital de Caridade da Irmandade da Santa Casa de Curitiba (BVCHSC), analysing aspects related to procurement, processing, storage and distribution of homologous cardiovascular grafts.
Method: Initial donor screening was achieved according the national guidelines for human organ procurement, besides specific BVCHSC criteria. Hearts were obtained from multiple organ donors, non-beating heart donors and heart transplant recipients, with total ischemic times under 48 hours. Donor ages varied from neonates up to 60 years for aortic valves and 65 years for pulmonary valves. The dissected grafts had their dimensions measured and their morphology evaluated, using a classification system with category 0 (discarded), 1 (minimal morphological alterations) and 2 (perfect). The incidence and microorganisms responsible for organ contamination were determined, as was the efficiency of the decontamination solution. Aspects related to graft distribution were also analysed.
Results: From September 1996 to February 2005, 1059 hearts from 19 Brazilian states were recevied at BVCHSC. From these, 977 (92.3%) were from brain-death donors. A total of 2105 grafts were processed and of the aortic and pulmonary grafts that were analysed, 783 were in category 2, 697 in category 1 and 186 were discarded due to morphological abnormalities. In total, 433 received grafts were contamined and the sterilization solution was efficient in 330 cases. 571 (27.1%) grafts were rejected during some phase of the processing, mainly due to contamination and morphological abnormalities. A total of 1338 grafts were distributed to 74 health institutions and were more commonly used for aortic valve replament (529), correction of congenital heart diseases (478) and during the Ross procedure (272).
Conclusions: The activities of the BVCHSC during the initial eight years were satisfactory, fulfilling the proposed goals.
Keywords: Tissue banks; Transplantation, homologous; Cryopreservation; Tissue preservation
Pulmonary function aspects after myocardial revascularization related to preoperative risk
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To compare the dynamic and static compliance, airway resistance values (Cdyn, Cst and Raw) and to gas exchange index (PaO2/FiO2) postoperative to Coronary Artery Bypass Surgery Graft (CABG) with normality parameters, and to compare the values of these variables between groups with and without preoperative risk factors.
Method: Questioning the patients about previous pulmonary diseases, respiratory symptomology, smoking, and comorbidities. After CABG measures were taken for Cdyn, Cst, Raw and the PaO2/FiO2. Variables were compared with normality and related to pre- and postoperative variables by the Mann-Whitney non-parametric Test and the Test for one proportion (p<0.05).
Result: Seventy patients were evaluated (61% men) aged between 26 and 77 years. With regard to normality, diminution of Cdyn and Cst was presented in 64 and 66 patients, respectively, and increase of Raw in 24. Approximately 50% presented reduction in PaO2/FiO2. There was no significant difference in postoperative variables about previous pulmonary diseases, respiratory symptomology and smoking. In patients with comorbidities was PaO2/FiO2 significantly less and, in men, Cdyn and Cst were greater than in women.
Conclusion: Pulmonary compliance is diminished in more than 90% of patients that undergo CABG; and the airway resistance is increased in one third of them. The gas exchange index is reduced in half of them. The present previous pulmonary diseases, respiratory symtomology and smoking did not influence mechanical variables, but the gas exchange index is influence by the presence of comorbidities.
Keywords: Respiratory mechanics; Thoracic surgery; Respiration, artificial; Postoperative complications; Myocardial revascularization
Myocardial metabolism after hypothermic retrograde continuous blood cardioplegia with anterograde warm cardioplegic induction
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: To determinate the alterations suffering by myocardium in the hypothermic retrograde continuous blood cardioplegia with antegrade warm cardioplegic induction.
Method: A metabolic analysis of hypothermic retrograde continuous blood cardioplegia with antegrade warm cardioplegic induction was performed in a prospective study of 15 patients scheduled for elective coronary artery bypass grafting. Arterial and coronary sinus blood samples were simultaneously taken: before establishing cardiopulmonary bypass, after anterograde warm cardioplegic induction, when the aortic clamp was removed and 10, 30 and 60 minutes after reperfusion to analyze the oxygen content and lactate concentration. Four transmural left ventricular biopsy samples were obtained: before aortic clamping, immediately after the initial cardioplegia bolus, immediately before aortic declamping and 30 minutes after reperfusion to analyze the levels of ATP, ADP, AMP and lactate in the myocardium. The CK-MB isoenzyme was analysed in venous blood samples.
Results: There were no mortalities in the group. Inotropic support was not necessary in any patients and no peri- or post-operative myocardial infarction was detected. There was a decrease in the arterial-venous extraction of oxygen and lactate in the heart during reperfusion, a partial recovery occurred at 60 minutes of reperfusion. The levels of ATP and the other nucleotides in the myocardium were maintained during aortic clamping, but these levels decreased during the first 30 minutes of reperfusion. The lactate accumulated in the heart muscle during aortic clamping with a decrease occurring during reperfusion.
Conclusions: From a metabolic point of view the method could not avoid an anaerobic metabolism during cross-clamping and only after 60 minutes of reperfusion there was a satisfactory metabolic recovery. These alterations are probably a reflection of cellular ischemic injury that occurs during cross-clamping and they seem to be of transitory effect. A better myocardium protection was observed with the addiction of anterograde warm induction cardioplegia.
Keywords: Cardioplegic solutions; Heart arrest, induced; Adenosine triphosphate; Lactic acid
St Jude Medical-Biocor bovine pericardial bioprosthesis: long-term survival
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Objective: The objective of this work is to present long-term results of valve replacement using SJM-BiocorTM bovine pericardial bioprostheses.
Methods: From 1992 to 2000, 304 patients were discharged from hospital after bioprosthesis implantation. Ages ranged from 15 to 83 years (mean: 60.6 ± 14.3 years) and 50.3% were male. Patient deaths and events related to bioprosthesis (infection, thromboembolism and structural failure) were considered for estimation of cumulative probability of survival and event-free survival.
Results: Total follow-up was 931.0 patients-year. During follow-up there were 28 (9.2%) deaths. Causes were bioprosthesis failure in five (1.6%), cardiac in seven (2.3%), non-cardiac in four (1.3%), and unknown in 12 (3.9%) patients. Events related to bioprosthesis were: endocarditis: 18 (5.9%), fibrocalcic degeneration: 15 (4.9%), thromboembolism: three (1.0%), hemolysis: one (0.3%). Bioprosthesis dysfunctions resulted in 16 (5.2%) reoperations due to fibrocalcic degeneration (nine), endocarditis (six) and thromboembolism (one). Probability of survival was higher in the young population (< 40 years, n=35) when compared to the older group (> 60 year, n=187): 82.0 ± 13.3% vs. 58.8 ± 13.6% in the 9th year. Event-free survival was 77.5 ± 3.7% for 5th year and 40.2 ± 9.0% for 10th year. Overall estimative of structural failure for a SJM-BiocorTM was 5% in 5th year increasing to 20% in the 10th year. In the aortic position the values were zero and 8%, respectively. Considering current clinical conditions, 88.5% are in NYHA class I, 9.1% in class II and 2.3% in class III.
Conclusions: SJM-BiocorTM bovine pericardial bioprostheses resulted in satisfactory survival of patients, related to low prevalence of bioprosthesis dysfunction.
Keywords: Bioprosthesis; Heart valve prosthesis; Heart valves
REVIEW ARTICLE
Technological evolution of membrane oxygenators
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
CASE REPORT
Coexistence of multiple mechanical complications from a single acute myocardial infarction: successful surgical treatment
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Pseudoaneurysms of the left ventricle and subpericardial aneurysms are rare complications of acute myocardium infarctions. This article is based on the case of a 68-year-old patient who developed an interventricular communication after an acute myocardium infarction. Surgical repair of this complication resulted in the coexistence of a pseudoaneurysm and a true aneurysm of the left ventricle as a late complication. A second surgical procedure was successful, based on resection of both complications with subsequent geometric reconstruction.
Keywords: Aneurysm false, surgery; Heart aneurysm, surgery; Heart ventricles, abnormalities
Coronary spasms after coronary artery bypass surgery: a case report and concise review of the literature
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Coronary artery spasms may occur as a serious complication during the trans-operative and immediate postoperative periods of coronary artery bypass surgery (CABS). The small number of cases reported is responsible for making it difficult not only to choose an adequate treatment but also to determine risk factors that might be responsible for its incidence. Coronary artery spasms have a multifactorial character, sudden appearance and must be part of the differential diagnosis of acute myocardial infarction and low output syndrome among patients submitted to heart surgery. We describe a case of a patient submitted to CABS with extracorporeal circulation who presented electrocardiographic alterations suggesting acute myocardial infarction during the immediate postoperative period but was diagnosed as having coronary artery spasms evidenced by a coronary catheterism performed afterwards. The patient was successfully treated with intracoronary vasodilators with good evolution over the short and medium terms.
Keywords: Coronary disease; Spasm; Myocardial revascularization; Coronary vasospasm
Capillary-type cardiac hemangioma, in the left atrium
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
A 49-year-old woman, whose echocardiography and hemodynamic study showed a mass in the left atrium suggestive of myxoma, was referred for cardiological evaluation because of dyspnea. She also had schistosomotic hepatosplenomegaly. After a preoperative evaluation with hematological assistance, the patient underwent surgery using a cardiopulmonary bypass. She suffered a hemorrhage in the immediate post-operative period, which improved after platelet transfusion. The histopathologic study showed a capillary-type cardiac hemangioma.
Keywords: Heart neoplasms, surgery; Heart atria, pathology; Hemangioma, diagnosis; Hemangioma, surgery
CLINICAL-SURGICAL CORRELATION
Joint applicability of endoprosthesis in reoperation of aortic dissection - Case 7/2005
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
Atriocavoplasty with atrial tissue in the treatment of upper sinus-venous type interatrial communication - Case 8/2005
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025
LETTERS TO THE EDITOR
Open letter to the President of the BSCVS
Braz J Cardiovasc Surg 20;
Publish in: 8/2/2025